A new study that looks at the risk of uterine rupture
during labor for VBACs (vaginal birth after cesarean-section) was
picked up by newspapers across the country, but many headlines
announced that VBACs are dangerous, a gross distortion of the study's
findings. National organizations including the ACNM and the
International Cesarean Awareness Network issued press releases, and
through the Grassroots Network CfM urged people to respond with letters
to the editor of their local newspapers.

The most important finding was that for hospital VBACs
(after one c-section) induction of labor significantly increases the
risk of uterine rupture, and the use of protoglandins greatly increases
the risk of rupture (15 times higher than those who had second
cesaraeans). In other words, the real problem is the first c-section
(which accounts for 2/3 of the US c-section rate of 22% in 1999), with
the risks greatly increased when labor is induced especially with
prostaglandins.

Data for women who had a first (single) baby by
c-section from 1987-1996, and subsequently gave birth to a second live
single infant during the same period of time (20,095 women, based on
Washington State records for hospital births), were analyzed in this
study. The study found:

Repeat c-section without labor

1.6

(11 of 6,980 women)

Spontaneous onset of labor

5.2

(56 of 10,789 women)

Labor induced without prostaglandins

7.7

(15 of 1,960 women)

Labor induced with prostaglandins

24.5

(9 of 366 women)

The study did not address many significant issues. For
example, uterine rupture can include anything from relatively minor
separations at the scar site, to sudden and catastrophic multiple large
tears of the uterus. However, accuracy of reported uterine rupture was
barely touched upon, and degrees of severity were not discussed.
Because the study focused only on the risk of uterine rupture, the
risks associated with the cesarean delivery procedure itself were not
discussed, even though these would be very relevant for informed
decision-making. There was no mention of other interventions that could
possibly affect outcomes, such as augmentation of labor (can cause
abnormally strong contractions) or the use of epidurals during labor
(can mask early symptoms of uterine rupture). The authors did
acknowledge that they lacked information regarding specific types and
dosages of prostaglandins used, although the controversial use of
Cytotec was not known to be used prior to the last year of the study.
Finally, there was no discussion or information regarding the timing
(number of weeks of gestation) or reasons for induction.

The study included only hospital births, and did not
distinguish between natural childbirth (no interventions) and standard
hospital-managed birth.

The study actually confirms what the midwifery
community has been saying for years: outcomes for VBACs that are
allowed to labor normally, without induction or augmentation, are good.
And women who have had a previous c-section are definitely not
candidates for labor inducing drugs, which exert added stress to a
uterine wall that is already weakened or at least changed by the scar
tissue.

Women who are making decisions about attempting a VBAC
should understand the results of this study (and its limitations). In
addition, this information is essential for any woman who is "offered"
an elective c-section, or whose caregiver recommends a
c-section, so she can be aware that a c-section today significantly
increases risks associated with any future pregnancy. Of course, she
should also have full information on the relative risks of any
c-section for herself and her baby.

As ICAN states in their press release (see below),
"the risk of uterine rupture [for a VBAC] remains low when labor
is allowed to start on its own."

"In fact,the
risk of rupture for women who begin labor spontaneously was shown to be
0.5%, lower than many other recent studies have shown and consistent
with the body of medical literature on VBAC. Women planning VBAC should
be encouraged that the risk of uterine rupture remains low when labor
is allowed to start on its own."

"In any discussion about VBAC, women must also be
provided with unbiased, evidence-based information about the known
risks of elective cesarean section. Babies delivered by elective
cesarean section are cut during surgery 2-6% of the time, have a 9%
chance of being born prematurely, and risk a 0.4% chance of developing
respiratory distress syndrome, a potentially fatal complication. They
spend more time in neonatal intensive care units and have more
breastfeeding difficulties than babies born vaginally."

"Cesareans also increase the risks to both mother and
baby in subsequent pregnancies. Incidences of life-threatening
placental abnormalities increase with each cesarean. When all short-
and long-term consequences are considered, VBAC has been shown to be
less risky for both mother and baby than elective repeat cesarean
section."

"Standing up to the VBAC-lash: A critique of the New
England Journal of Medicine VBAC study and implications for the future
of the medical model of childbirth." by Jill MacCorkle. Published on
the Internet (click here). This is a thorough and well-referenced paper
that also includes information regarding the risks associated with
c-sections in general and the evidence supporting the benefits of
VBACs.

Birth is the leading reason for hospital admission in
this country. Cesarean delivery is the most common surgery performed in
the United States. The most common cause of death in postpartum women
is complications from cesarean delivery.

In the face of these facts, it is shameful that the
media response to the New England Journal of Medicine study (July 5,
2001) has been to focus on the risks of vaginal birth, and not the
risks of routine medical interventions, such as prostaglandin induction
and elective repeat cesarean.

The study points to a 0.5% risk of rupture among
post-cesarean women who labor without induction. Other studies have
produced similar numbers that were used to support the practice of
VBAC. Why? Because even with this risk, the mother is still twice as
likely to die from complications of elective repeat cesarean birth
compared to vaginal birth.

Every maternity care provider has an ethical obligation
to honestly describe both options to the mother as part of her informed
decision-making process. Apparently there is no such obligation in the
public dialogue of this issue - there is no patient, only a large and
suggestible audience.

Sincerely,Susan Hodges, President, Citizens for MidwiferyWilla Powell, Board Member, Citizens for MidwiferyCitizens for Midwifery is the only national consumer organization advocating the Midwives Model of Care